Pediatric advocacy: Advancement in academic institutions.

IMPACT: Children are facing many threats to their health today that require system change at a sweeping level to have real-world impact. Pediatricians are positioned as natural leaders to advocate for these critical community and policy changes. Academic medical center (AMC) leaders recognize the importance of this advocacy and clear steps can be taken to improve the structure to support pediatricians in their advocacy careers through faculty development and promotion, including standardized scholarly measurement of the outcomes.

DC Mental Health Access in Pediatrics: Evaluating a Child Psychiatry Access Program in Washington, DC.

INTRODUCTION: Child psychiatry access programs (CPAPs) provide primary care providers (PCPs) with assistance in mental health diagnosis, management, and resource navigation. METHOD: Data collected from DC Mental Health Access in Pediatrics (MAP) included PCPs and patient demographics, clinical encounter information, and provider satisfaction. RESULTS: DC MAP consult volume increased 349.3% over the first 5 years. Services requested included care coordination (85.8%), psychiatric consultation (21.4%), and psychology/social work consultation (9.9%). Of psychiatry-involved consultations, PCPs managed patient medication care with DC MAP support 50.5% of the time. Most (94.1%) PCPs said they would recommend colleagues use DC MAP, and 29.6% reported diverting patients from the emergency departments using DC MAP. DISCUSSION: DC MAP grew quickly, highlighting program impact and need. Demand for care coordination required flexible staffing and highlighted the need for coordination in pediatrics. Child psychiatry access programs offer an innovative way to enhance PCP management of their patients' mental health needs.

The Family is the Patient: Promoting Early Childhood Mental Health in Pediatric Care.

Advances in developmental psychology, child psychiatry, and allied disciplines have pointed to events and experiences in the early years as the origin of many adult mental health challenges. Yet, children's mental health services still largely lack a developmental or prevention-focused orientation, with most referrals to mental health professionals occurring late, once problems are well established. An early childhood mental health system rooted in the principles of life-course health development would take a very different approach to designing, testing, and implementing prevention and intervention strategies directed toward early child mental health. Priorities for such a system include supporting healthy family environments, parent-child and family relationships, parents' emotional/behavioral health, and family routines as a means of providing the best possible neurobiological foundation for mental health across the life span. The system would include proactive, trauma-informed, multidisciplinary care, with integrated mental health and social services support embedded in pediatric primary care settings. Novel intervention approaches in need of further research include 2-generational dyadic interventions designed to improve the mental health of parents and children, mental health-oriented telemedicine, and contingency management (CM) strategies. Integral to this Life Course Health Development reformulation is a commitment by all organizations supporting children to primordial and primary prevention strategies to reduce racial and socioeconomic disparities in all settings. We contend that it is the family, not the individual child, that ought to be the identified target of these redesigned approaches, delivered through a transformed pediatric system with anticipated benefits for multiple health outcomes across the life course.

Advancing Antiracism in Community-Based Research Practices in Early Childhood and Family Mental Health.

Structural racism-the ways that institutional policies, practices, and other norms operate to create and sustain race-based inequities1-has historically been foundational to the operations of academic medical centers and research institutions. Since its inception, academic medicine has depended on the exploitation of vulnerable communities to achieve medical, educational, and research goals.2 Research practices have long ignored or taken advantage of the individuals purportedly benefiting from the research, a dynamic most manifestly true for Black, Indigenous, and People of Color (BIPOC) communities in the United States. Reflecting current practices in racial justice work, we intentionally use the term "BIPOC" to highlight shared experiences within racially and ethnically minoritized communities, given the history of White supremacy in the United States. We acknowledge limitations of this term, which collapses myriad unique communities and histories into one construct. Specifically, child and adolescent psychiatry has historically been driven by Eurocentric approaches, paradigms, and methodology. These nonparticipatory dominant research practices have contributed to a lack of culturally responsive interventions for BIPOC communities, a paucity of evidence-based practices with demonstrated effectiveness within BIPOC communities, and disparities in access and quality of care.3 Mental health research involving BIPOC communities has been replete with exploitation and inequality.2.

A Primary Care Intervention to Prevent Repeat Pregnancy Among Teen Mothers.

INTRODUCTION: The purpose of this study is to determine the effectiveness of a patient-centered medical home intervention for teen parent families in reducing rates of unintended repeat pregnancy in the first 2 years postpartum. METHODS: A prospective quasi-experimental evaluation was conducted with 98 African American, low-income, teen mother (aged <20 years) participants who received either the intervention or standard pediatric primary care. All participants completed structured interviews at baseline (child aged 2 months) and at follow-ups 12 and 24 months later. Data were collected from 2011 to 2015. Participants reported number of pregnancies, contraception used at last intercourse, depressive symptoms, and romantic status of the relationship with the baby's father. Analyses were conducted from 2015 to 2017. RESULTS: Logistic regression showed that mothers in the intervention group were half as likely as mothers who received standard pediatric primary care to have a repeat pregnancy within 2 years (OR=0.55, p=0.16). The main effect of the intervention on lower rates of repeat pregnancy was mediated by higher rates of contraceptive use. Depression was associated with higher odds of repeat pregnancy, but did not appear to mediate the intervention effect. CONCLUSIONS: This comprehensive and integrated model of care for teen parents may be an effective method to prevent rapid repeat pregnancies in this vulnerable population.

The Advocacy Portfolio: A Standardized Tool for Documenting Physician Advocacy.

Recent changes in health care delivery systems and in medical training have primed academia for a paradigm shift, with strengthened support for an expanded definition of scholarship. Physicians who consider advocacy to be relevant to their scholarly endeavors need a standardized format to display activities and measure the value of health outcomes to which their work can be attributed. Similar to the Educator Portfolio, the authors here propose the Advocacy Portfolio (AP) to document a scholarly approach to advocacy.Despite common challenges faced in the arguments for both education and advocacy to be viewed as scholarship, the authors highlight inherent differences between the two fields. On the basis of prior literature, the authors propose a broad yet comprehensive set of domains to categorize advocacy activities, including advocacy engagement, knowledge dissemination, community outreach, advocacy teaching/mentoring, and advocacy leadership/administration. Documenting quality, quantity, and a scholarly approach to advocacy within each domain is the first of many steps to establish congruence between advocacy and scholarship for physicians using the AP format.This standardized format can be applied in a variety of settings, from medical training to academic promotion. Such documentation will encourage institutional buy-in by aligning measured outcomes with institutional missions. The AP will also provide physician-advocates with a method to display the impact of advocacy projects on health outcomes for patients and populations. Future challenges to broad application include establishing institutional support and developing consensus regarding criteria by which to evaluate the contributions of advocacy activities to scholarship.

Mental Health Screening Quality Improvement Learning Collaborative in Pediatric Primary Care.

BACKGROUND: In the United States, up to 20% of children experience a mental health (MH) disorder in a given year, many of whom remain untreated. Routine screening during annual well visits is 1 strategy providers can use to identify concerns early and facilitate appropriate intervention. However, many barriers exist to the effective implementation of such screening. METHODS: A 15-month quality improvement learning collaborative was designed and implemented to improve screening practices in primary care. Participating practices completed a survey at 3 time points to assess preparedness and ability to promote and support MH issues. Monthly chart reviews were performed to assess the rates of screening at well visits, documentation of screening results, and appropriate coding practices. RESULTS: Ten practices (including 107 providers) were active participants for the duration of the project. Screening rates increased from 1% at baseline to 74% by the end of the project. For the 1 practice for which more comprehensive data were available, these screening rates were sustained over time. Documentation of results and appropriate billing for reimbursement mirrored the improvement seen in screening rates. CONCLUSIONS: The learning collaborative model can improve MH screening practices in pediatric primary care, an important first step toward early identification of children with concerns. More information is needed about the burden placed on practices and providers to implement these changes. Future research will be needed to determine if improved identification leads to improved access to care and outcomes.

Using Effective Public Private Collaboration to Advance Integrated Care.

Integrated mental health services within health care settings have many benefits; however, several key barriers pose challenges to fully implemented and coordinated care. Collaborative, multistakeholder efforts, such as health networks, have the potential to overcome prevalent obstacles and to accelerate the dissemination of innovative clinical strategies. In addition to engaging clinical experts, efforts should also include the perspectives of families and communities, a grounding in data and evaluation, and a focus on policy and advocacy. This article describes how one community, Washington, DC, implemented a health network to improve the integration of mental health services into pediatric primary care.

Strengthening positive coparenting in teen parents: a cultural adaptation of an evidence-based intervention.

Teen childbearing is associated with a range of adverse outcomes for both mothers and children, and perpetuates an intergenerational cycle of socioeconomic disadvantage. Fathers may be an underappreciated source of support to teen mothers and their children. The strongest and most consistent predictor of positive father involvement is a positive coparenting relationship between the mother and father. Thus, strengthening the coparenting relationship of teen parents may be protective for both parents and children. This paper describes the rationale, the intervention model, and the cultural adaptation of Strong Foundations, an intervention designed to facilitate and enhance positive coparenting in teen parents. Adapted from an evidence-based coparenting program for adult, cohabiting parents, this intervention was modified to be developmentally and culturally appropriate, acceptable, and feasible for use with urban, low-income, minority expectant teen mothers and their male partners. The authors present lessons learned from the cultural adaptation of this innovative intervention. Pilot testing has shown that this model is both acceptable and feasible in this traditionally hard to reach population. Although recruitment and engagement in this population present specific challenges, young, urban minority parents are deeply interested in being effective coparents, and were open to learning skills to support this goal.

Pregnancy intentions among expectant adolescent couples.

STUDY OBJECTIVE: To examine the self-reported pregnancy intentions of the male partners of expectant adolescent mothers, the accuracy of adolescent mothers' perceptions of their partner's pregnancy intentions, and the concordance between young mothers' and fathers' pregnancy intentions. DESIGN: This cross-sectional pilot study collected interview data from expectant adolescent mothers and their male partners. SETTING: Data were collected in participants' homes. PARTICIPANTS: 35 expectant couples were interviewed separately. Most participants were African American (89% of mothers, 74% of fathers). 69% of mothers were 17-18 years old, and half of the fathers were ≥19. MAIN OUTCOME MEASURES: Parents responded to survey questions adapted from the Center for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System Questionnaire. RESULTS: 44% of fathers reported wanting their partner to get pregnant. Another 15% were ambivalent. A kappa statistic of 0.12 (P = .33) indicated very little "accuracy" of mothers' perceptions of their partners' pregnancy intentions. Further, there was low concordance between the pregnancy intentions of mothers and fathers. Young fathers who wanted or were ambivalent about pregnancy were significantly more likely to use no contraception or withdrawal. CONCLUSION: For a notable number of minority couples, adolescent mothers do not have an accurate perception of their partners' pregnancy intentions and use contraceptive methods that are not within their control. These findings indicate that teen pregnancy prevention interventions must target young males in addition to females and sexually active adolescents should be encouraged to discuss pregnancy intentions with each other.

Coparenting in teen mothers and their children's fathers: evidence from the early childhood longitudinal study-birth cohort.

OBJECTIVE: (1) To describe coparenting among adolescent mothers and the biological fathers of their children. (2) To examine the effects of coparenting on young children's social-emotional development and whether these effects vary by father's residence status, parental education, and child characteristics. METHODS: Secondary analysis was conducted with the Early Childhood Longitudinal Study-Birth Cohort, which is a nationally representative sample of U.S. children born in 2001. The subsample used in this study includes 400 children whose biological mothers, aged 15-19, participated when their children were 2 years and 4 years old and whose biological fathers (residential and nonresidential) participated at 4 years. Cooperative coparenting and coparenting conflict were measured at child age 2 years. Children's social skills and problem behavior were measured at child age 4 years. RESULTS: Mother- and father-reported coparenting conflict were associated with child behavior problems, more strongly among boys (b = 1.31, P < .01) than girls (b = -0.13, P > .05). Mother-reported coparenting conflict also predicted lower child social skills (b = -1.28, P < .05); the association of father-reported coparenting conflict with social skills was moderated by child race and father education. CONCLUSIONS: Coparenting conflict between adolescent parents influences child adjustment. Practitioners working with teen mothers should encourage father participation at medical visits and other clinical contacts and should address the relationship between the parents, whether or not they are living together, as part of routine care.